What are effective anxiety medications in a hospital setting that do not require Intravenous (IV) access?

Effective Anxiety Medications in Hospital Without IV Access

For hospitalized patients requiring anxiety management without IV access, oral benzodiazepines, intramuscular lorazepam, sublingual lorazepam, and intranasal medications are the most effective non-IV options, with selection based on severity and onset requirements. These medications can effectively manage anxiety while maintaining patient safety and comfort in situations where intravenous access is unavailable or undesirable.

First-Line Options

Oral Medications

• Benzodiazepines: First-line for rapid anxiety relief

  • Lorazepam (Ativan): 0.5-2 mg PO every 4-6 hours PRN
  • Midazolam: 7.5-15 mg PO for moderate anxiety
  • Diazepam: 5-10 mg PO every 6-8 hours PRN

• Antipsychotics: For agitated patients or when benzodiazepines are contraindicated

  • Olanzapine: 2.5-5 mg PO (also available as orally disintegrating tablet)
  • Quetiapine: 25 mg immediate release PO every 12 hours
  • Risperidone: 0.5 mg PO every 12 hours (also available as orally disintegrating tablet)

Intramuscular Options

• Lorazepam: 1-2 mg IM PRN 1 - particularly useful when oral route is not feasible
• Olanzapine: 2.5-5 mg IM
• Haloperidol: 0.5-1 mg IM (may cause extrapyramidal side effects)
• Midazolam: 2.5 mg IM for acute anxiety

Alternative Routes

• Sublingual/Buccal: Lorazepam can be administered sublingually 2
• Intranasal: Effective for rapid onset, especially in children 2
• Rectal: Diazepam can be administered rectally when other routes unavailable

Clinical Decision Algorithm

1. Assess anxiety severity and urgency:

   • Mild to moderate: Start with oral medications
   • Severe or requiring rapid onset: Consider IM or alternative routes

2. Consider patient factors:

   • Respiratory status (avoid benzodiazepines in severe respiratory compromise)
   • Hemodynamic stability (use caution with antipsychotics in unstable patients)
   • History of substance abuse (consider non-benzodiazepine options)
   • Age and frailty (use lower doses in elderly/frail patients)

3. Route selection based on clinical scenario:

   • Alert patient who can swallow: Oral route preferred
   • Unable to swallow or rapid onset needed: IM lorazepam or olanzapine
   • Combative patient: IM ketamine may be considered 2
   • Pediatric patient: Intranasal options preferred 2

Special Considerations

Elderly Patients

• Use lower starting doses (e.g., lorazepam 0.25-0.5 mg)
• Monitor closely for paradoxical reactions, respiratory depression
• Consider non-benzodiazepine options when possible

Patients with Respiratory Compromise

• Avoid or use reduced doses of benzodiazepines
• Consider antipsychotics as alternatives
• Monitor oxygen saturation closely

Agitated/Combative Patients

• IM ketamine may be used when IV access is difficult 2
• Oral sedation may be considered before attempting physical restraint
• Target level of sedation: patient should be quiet but responsive to verbal or painful stimuli

Common Pitfalls to Avoid

1. Oversedation: Start with lower doses and titrate up as needed
2. Drug interactions: Be aware of potential interactions with other CNS depressants
3. Respiratory depression: Monitor respiratory status closely, especially with benzodiazepines
4. Paradoxical reactions: Particularly in elderly patients and children
5. Excessive physical restraint: Can worsen agitation and cause physiological harm 2

For optimal outcomes, implement non-pharmacological anxiety management techniques alongside medication, including creating a calm environment, using distraction techniques, and employing a single point of contact for agitated patients 2.